1.         The present Revision Petition (RP) has been filed by the Petitioner against Respondents as detailed above, under section 21(b) of Consumer Protection Act 1986, against the order dated 29.06.2020 of the State Consumer Disputes Redressal Commission, Punjab (hereinafter referred to as the ‘State Commission’), in First Appeal (FA) No. 697/2019 in which order dated 22.08.2019 of District Consumer Disputes Redressal Forum, Hoshiarpur (hereinafter referred to as District Forum) in Consumer Complaint (CC) No. 175/2018 was challenged, inter alia praying for setting aside the order dated 29.06.2020 passed by the State Commission.

2.         While the Revision Petitioner (hereinafter also referred to as Complainant) was Respondent before the State Commission and Complainant before the District Forum and the Respondent(s) (hereinafter also referred to as OPs/Insurance Company) were Appellants before the State Commission and Opposite Parties before the District Forum.

3.         Notice was issued to the Respondent(s) on 06.09.2021.  Parties filed Written Arguments on 13.09.2022 (Petitioner) and 19.09.2022 (Respondents) respectively. 

4.         Brief facts of the case, as presented by the Complainant and as emerged from the RP, Order of the State Commission, Order of the District Forum and other case records are that:

The Complainant/Petitioner herein obtained medi-claim Insurance Policy form the OPs/Insurance Company for the period from 21.07.2017 to 30.07.2018 for risk coverage of Rs.1,00,000/-.  The Petitioner paid the premium of Rs.9505/-for the said policy.  On 25.01.2018, the Petitioner met with a road-side accident and suffered face and mouth injury.  He was taken to Dr. Sahni Advanced Dental Practice, Hoshiarpur.  The attending doctor advised for operation of upper jaw, root canal and splinting of upper teeth. On advise of the doctor, the petitioner got treatment from 26.01.2018 till 07.02.2018 and spent Rs.1,50,000/- for surgery, treatment and medication.  On 01.03.2018, the petitioner submitted the claim to the Respondent/Insurance Company with all the documents.  On 23.03.2018, the Respondent repudiated the claim of the Petitioner. The Petitioner sent a legal notice to the Respondent on 05.10.2018 requesting to pay the insurance medi-claim amount along with benefits, but the Respondent did not reply to the notice.  Hence, the complainant filed complaint before the District Forum.

5.         Vide Order dated 22.08.2019, in the CC No.175/2018, the District Forum has allowed the complaint.

6.         Aggrieved by the said Order dated 22.08.2019 of District Forum,  Respondents appealed in State Commission and the State Commission vide order dated 29.06.2020 allowed FA No. 697/2019 and dismissed the complaint filed by the complainant/petitioner herein before the District Forum.

7.         Petitioner has challenged the said Order dated 22.08.2019 of the State Commission mainly on following grounds:

1. The judgment and order dated 29.06.2020 passed by the State Commission is bad in the eye of law and/or in facts. The State Commission failed to exercise the power so vested in it at the time of passing the impugned judgment.  The State Commission erred in law by not considering the relevant clauses of the terms and conditions. The order passed by the State Commission discloses error apparent on the face of the records and as such it is illegal, void and resulted to miscarriage of justice.

2. The State Commission erred in not appreciating the negligence on the part of the Respondent despite the contract made between the Petitioner and the Respondent is based on the principle of uberrima fides, so it is necessary to consider the relevant clauses in the term and condition of the respondent.

3. The State Commission erred in not appreciating the grounds taken in the appeal are analogues to the objection taken by the Respondent in the written statement before the District Forum. Therefore, the grounds taken in the Appeal by the Respondent are after contemplation and deliberation.

4. The State Commission failed to appreciate the case in proper perspective and therefore the order dated 29.06.2020 is perverse and contrary to the law and facts of the case.

8.         Heard counsels of both sides.  Contentions/pleas of the parties, on various issues raised in the RP, Written Arguments, and Oral Arguments advanced during the hearing, are summed up below.

8.1 The Petitioner contends that the complainant got a medical claim insurance policy from the OP by paying Rs.9505/- as premium on 06.07.2017.  The OP issued an insurance policy for the period from 21.07.2017 to 20.07.2018.  As per the policy the risk upto Rs.1,00,000/- was covered.  The complainant met with a roadside accident and suffered face and mouth injury.  The complainant was taken to Dr. Sahni, Advanced dental Practice, Hosiarpur.  The attended doctor operated upon the upper jaw injury, root canal and sprinting of upper teeth of the complainant and the complainant had to go treatment from doctor Sahni from 26.01.2018 to 07.02.2018 and spent Rs.1,50,000/- for surgery, treatment, medication , care and follow up.  The claim applied by the complainant was repudiated by the OP vide letter dated 23.08.2018.  It is further contended that as per the medi-claim policy rules clause 3.14.1, it is clearly mentioned in the case of Dental Surgery following an accident the time limit of the 24 hours will not be applicable.  In Clause 3.14.1-Hospitalization: means admission in a Hospital for a minimum period of 24 in patients Care consecutive hours except for specified procedures/treatments, where such admission could be for a period of less than 24 hours consecutive hours.  It is clearly mentioned in this clause that the time limit of 24 hours will not be applicable for following surgeries/procedures and the Dental Surgery following an accident is one of the contents of the clause.  OP has taken a stand that no OPD record of patient has been found and the treatment was taken in the Clinic, no OPD register available and further alleged that the treatment was taken on OPD basis and it does not fulfill the definition of “Hospital” and as such, the claim of the complainant was repudiated.   It is also contended by the Petitioner that the insurance policy is not in dispute and the accident was occurred on 25.01.2018 during the currency of the said policy.  The complainant has furnished the OPD slips of the said Clinic where he has taken the treatment/surgery and he has paid Rs.1,50,000/- for the same.  The OP has repudiated the claim under the above said clause arbitrarily.  No investigation report as well as affidavit of investigator has been produced on the file.  In support of his contention the Petitioner has relied upon the following judgments:

(a)       Judgment passed by National Commission in Mankant Vs. New India Assurance Co. Ltd. 1(2012) CPJ 88.

(b)       Judgment passed  by the Hon’ble Apex Court in Dharmendra Goel Vs. Oriental Insurance Co. Ltd. III (2008) CPJ 63 (SC).

(c )      Judgement passed by Hon’ble Pb. & Haryana High Court in New India Assurance Co. Ltd. Vs. Smt. Usha Yadav & Ors. 2008 (3) RCR (Civil) page 111.

            8.2       On the other hand Respondents/Insurance Company contended that  the complainant raised the insurance claim of Rs.1,50,000/- with the Respondent Company.  On receipt of the claim request, Third Party Administrator of the Respondent M/s Raksha had written to Petitioner to supply the documents for settlement of claim.  In the absence of any vital document or MLC to prove the accident of the petitioner, the Respondent repudiated the claim on the grounds that i) there should be hospitalization of minimum 24 hours, ii) this requirement is exempted in case of accident, Rules clause 3.14.1 mentions that in case of dental surgery following an accident the time limit of the 24 hours will not be application. The Petitioner was not admitted in the hospital and took the plea of accident just to grab the claim money.  No MLC provided by the petitioner despite being asked by the Surveyor, which is ample proof to show that there was no accident which was alleged to have happened with the Petitioner.  The hospital record proves the purpose of hospital visit by the petitioner.  He had undergone RCT which is done when there is deep infection within the tooth.  The District Forum allowed the complaint filed by the complainant.  However, the State Commission allowed the appeal filed by the Respondents herein.  In support of their contentions, the OPs have relied upon the following judgments:

            (a) M/s Ghai Agro Ltd. Vs. New India Assurance Co. Ltd. reported in Supreme Court & National Commission on Consumer Law Cases 986-2005-pg. 404.

            (b)  Vikram Greentech (I) Ltd. & Anr. Vs. New India Assurance Co. Ltd. 2009 (4) CLT 313; Deokar Exports Pvt. Ltd. Vs. New India Assurance Co. Ltd. 2009 (2) CLT 15; LIC of India & Ors. Vs. Mahendra Singh 2011 (4) CLT 39.

9.         We have carefully gone through the orders of the State Commission, District Forum, other relevant records and contentions of the parties.  The main contention of the Respondent/Insurance Company is that for the claim to be eligible, there should be hospitalization for minimum 24 hours.  This requirement is exempted in case the insured has suffered injuries in an accident.  It is the case of Insurance Company that Complainant was not admitted in hospital for 24 hours and took the plea of accident just to get the claim from Insurance Company.  On the other hand, it is the case of Complainant that he met with a roadside accident and suffered face and mouth injury.  In this regard, State Commission, after appreciating the evidence on record, has observed as follows:-

“14.         From the above treatment bill it is evident RCT's were done for 5 Nos. teeth of upper jaw whereas fixed bridge was fitted for 13 Nos. teeth. No explanation to this effect has been given by the treating doctor. The respondent/complainant has undergone a long dental treatment due to accident but no treatment record for associated injuries have been explained. In an accident if the upper jaw has broken to this extent then there must be associated injuries on face which has not been explained. 

xxxx

16. No such document i.e. copy of MLC, Pre-post procedure X- ray films has been produced in evidence by the respondent / complainant. No document to evident accident except a slip of doctor has been produced. Even no affidavit of treating doctor has been placed in record.

17. In view of the above observations, there is no evidence of accident occurred and without any evidence available on the record, the appellants-Insurance Company cannot be compelled to allow the claim of the complainant. The appellants-Insurance Company is found to be justified in repudiating the claim of the complainant.”

10.       The State Commission has given a well-reasoned order and we are in agreement with its observations and findings.  There is no reliable and cogent evidence on record to show that the dental treatment undergone by the Petitioner/Complainant was on account of accident, as claimed.  As has been held by Hon’ble Supreme Court in catena of judgments[1] that revisional jurisdiction of the National Commission is extremely limited, it should be exercised only in case as contemplated within the parameters specified in the provision i.e. when State Commission had exercised a jurisdiction not vested in it by law or had failed to exercise jurisdiction so vested or had acted in the exercise of its jurisdiction so vested or had acted in the exercise of its jurisdiction illegally or with material irregularity.  It is only when such findings are found to be against any provisions of law or against the pleadings or evidence or are found to be wholly perverse, a case for interference may call for at the second appellate (revisional) jurisdiction. There is no illegality or material irregularity or jurisdictional error in the orders of State Commission, hence the same is upheld.  Accordingly the Revision Petition is dismissed.

11. The pending IAs in the case, if any, also stand disposed off.